Decision Report 201609388

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received during admissions to St John's Hospital, the Royal Infirmary of Edinburgh and the Western General Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing Mrs A's lymphoma (a type of cancer) during those admissions.

We took independent advice from a consultant upper-gastrointestinal surgeon and from a consultant physician. We found that appropriate investigations were carried out into Mrs A's condition. However, we found lymphoma is very difficult to diagnose and that it had presented in Mrs A in a very unusual way. We did find that Mrs A was unreasonably diagnosed with an autoimmune condition at St John's Hospital, based on blood test results that actually suggested inflammation. We found that an opinion from other relevant specialists may have avoided this misdiagnosis. We found that this error may have delayed her diagnosis of lymphoma by one month and we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for misdiagnosing Mrs A with an autoimmune condition. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Blood test results should be carefully reviewed, with the input of other medical specialists when appropriate.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.